Evidence-Based Nonpharmacologic Strategies for Comprehensive Pain Care: The Consortium Pain Task Force White Paper

The autobiographical memory system and chronic pain: A neurocognitive framework for the initiation and maintenance of chronic pain

Chronic pain affects approximately 20% of the world's population, exerting a substantial burden on the affected individual, their families, and healthcare systems globally. Deficits in autobiographical memory have been identified among individuals living with chronic pain, and even found to pose a risk for the transition to chronicity. Recent neuroimaging studies have simultaneously implicated common brain regions central to autobiographical memory processing in the maintenance of and susceptibility to chronic pain. The present review proposes a novel neurocognitive framework for chronic pain explained by mechanisms underlying the autobiographical memory system. Here, we 1) summarize the current literature on autobiographical memory in pain, 2) discuss the role of the hippocampus and cortical brain regions including the ventromedial prefrontal cortex, anterior temporal lobe, and amygdala in relation to autobiographical memory, memory schemas, emotional processing, and pain, 3) synthesize these findings in a neurocognitive framework that explains these relationships and their implications for patients' pain outcomes, and 4) propose translational directions for the prevention, management, and treatment of chronic pain.

Determinants of implementation for group medical visits for patients with chronic pain: a systematic review

BACKGROUND

Despite the critical need for comprehensive and effective chronic pain care, delivery of such care remains challenging. Group medical visits (GMVs) offer an innovative and efficient model for providing comprehensive care for patients with chronic pain. The purpose of this systematic review was to identify barriers and facilitators (determinants) to implementing GMVs for adult patients with chronic pain.

METHODS

The review included peer-reviewed studies reporting findings on implementation of GMVs for chronic pain, inclusive of all study designs. Pubmed, EMBASE, Web of Science, and Cochrane Library were searched. Studies of individual appointments or group therapy were excluded. The Mixed Methods Appraisal Tool was used to determine risk of bias. Data related to implementation determinants were extracted independently by two reviewers. Data synthesis was guided by the updated Consolidated Framework for Implementation Research.

RESULTS

Thirty-three articles reporting on 25 studies met criteria for inclusion and included qualitative observational (n = 8), randomized controlled trial (n = 6), quantitative non-randomized (n = 9), quantitative descriptive (n = 3), and mixed methods designs (n = 7). The studies included in this review included a total of 2364 participants. Quality ratings were mixed, with qualitative articles receiving the highest quality ratings. Common multi-level determinants included the relative advantage of GMVs for chronic pain over other available models, the capability and motivation of clinicians, the cost of GMVs to patients and the health system, the need and opportunity of patients, the availability of resources and relational connections supporting recruitment and referral to GMVs within the clinic setting, and financing and policies within the outer setting.

CONCLUSIONS

Multi-level factors determine the implementation of GMVs for chronic pain. Future research is needed to investigate these determinants more thoroughly and to develop and test implementation strategies addressing these determinants to promote the scale-up of GMVs for patients with chronic pain.

TRIAL REGISTRATION

This systematic review was registered with PROSPERO 2021 CRD42021231310 .

An Adaptive Pragmatic Randomized Controlled Trial of Emergency Department Acupuncture for Acute Musculoskeletal Pain Management

STUDY OBJECTIVE

Acute musculoskeletal pain in emergency department (ED) patients is frequently severe and challenging to treat with medications alone. The purpose of this study was to determine the feasibility, acceptability, and effectiveness of adding ED acupuncture to treat acute episodes of musculoskeletal pain in the neck, back, and extremities.

METHODS

In this pragmatic 2-stage adaptive open-label randomized clinical trial, Stage 1 identified whether auricular acupuncture (AA; based on the battlefield acupuncture protocol) or peripheral acupuncture (PA; needles in head, neck, and extremities only), when added to usual care was more feasible, acceptable, and efficacious in the ED. Stage 2 assessed effectiveness of the selected acupuncture intervention(s) on pain reduction compared to usual care only (UC). Licensed acupuncturists delivered AA and PA. They saw and evaluated but did not deliver acupuncture to the UC group as an attention control. All participants received UC from blinded ED providers. Primary outcome was 1-hour change in 11-point pain numeric rating scale.

RESULTS

Stage 1 interim analysis found both acupuncture styles similar, so Stage 2 continued all 3 treatment arms. Among 236 participants randomized, demographics and baseline pain were comparable across groups. When compared to UC alone, reduction in pain was 1.6 (95% confidence interval [CI]: 0.7 to 2.6) points greater for AA+UC and 1.2 (95% CI: 0.3 to 2.1) points greater for PA+UC patients. Participants in both treatment arms reported high satisfaction with acupuncture.

CONCLUSION

ED acupuncture is feasible and acceptable and can reduce acute musculoskeletal pain better than UC alone.

Teaching Strategies for Nonpharmacological Pain Management to Nursing Students

BACKGROUND

Pain management is an essential concept to be integrated throughout undergraduate nursing curricula. Many studies have identified a lack of knowledge in pain assessment and management among nurses. Educators have significant roles in preparing students with pain knowledge and application of alternative nonpharmacological pain management techniques.

AIM

The purpose of this research study was to explore the impact of instruction on nonpharmacological pain management techniques in both didactic and simulated laboratory settings on nursing students' application of these techniques in clinical settings.

DESIGN

A mixed-method descriptive study, with a survey that included closed and open-ended questions.

PARTICIPANTS

The sample included 144 first-semester senior prelicensure baccalaureate nursing students.

METHOD

Investigators developed two research questionnaires. All students were given nonpharmacological pain management instruction didactically and practiced in the simulation lab and a hospital-based obstetrical practicum under faculty supervision. The students completed research questionnaires at the semester's conclusion and again prior to graduation.

RESULTS

Students reported that they implemented taught nonpharmacological pain management techniques in the clinical setting under faculty supervision. A review of the follow-up questionnaire indicates that graduating seniors did implement the nonpharmacological pain management techniques in other clinical settings and plan to utilize them in their future nursing practice.

CONCLUSIONS

Teaching nonpharmacological pain management techniques didactically, in a simulation lab and a supervised clinical setting contributes to students' ability to apply these techniques. The findings of this study have implications for nursing education and students' future clinical practice to foster their utilization of nonpharmacological pain management techniques across all settings.

Program of All-Inclusive Care for the Elderly: an untapped setting for research to advance pain care in older persons

The Program of All-Inclusive Care for the Elderly (PACE) is a community-based care model in the United States that provides comprehensive health and social services to frail, nursing home-eligible adults aged 55 years and older. PACE organizations aim to support adequate pain control in their participants, yet few evidence-based pain interventions have been adopted or integrated into this setting. This article provides a roadmap for researchers who are interested in collaborating with PACE organizations to embed and evaluate evidence-based pain tools and interventions. We situate our discussion within the Consolidated Framework for Implementation Research (CFIR), a meta-theoretical framework that considers multi-level influences to implementation and evaluation of evidence-based programs. Within each CFIR domain, we identify key factors informed by our own work that merit consideration by research teams and PACE collaborators. Inner setting components pertain to the organizational culture of each PACE organization, the type and quality of electronic health record data, and availability of staff to assist with data abstraction. Outer setting components include external policies and regulations by the National PACE Association and audits conducted by the Centers for Medicare and Medicaid Services, which have implications for research participant recruitment and enrollment. Individual-level characteristics of PACE organization leaders include their receptivity toward new innovations and perceived ability to implement them. Forming and sustaining research-PACE partnerships to deliver evidence-based pain interventions pain will require attention to multi-level factors that may influence future uptake and provides a way to improve the health and well-being of patients served by these programs.

Celecoxib alleviates the DSS-induced ulcerative colitis in mice by enhancing intestinal barrier function, inhibiting ferroptosis and suppressing apoptosis

INTRODUCTION

Ulcerative colitis (UC) is an inflammatory intestine disease characterized by dysfunction of the intestinal mucosal barrier, ferroptosis, and apoptosis. Previous researches suggest that celecoxib, a nonsteroidal anti-inflammatory drug, holds promise in alleviating inflammation in UC. Therefore, this study aims to investigate the effects and mechanisms of celecoxib in UC.

METHODS

To identify ferroptosis-related drugs and genes associated with UC, we utilized the Gene Expression Omnibus (GEO), FerrDb databases, and DGIdb database. Subsequently, we established a 2.5% DSS (Dextran sulfate sodium)-induced colitis model in mice and treated them with 10 mg/kg of celecoxib to validate the bioinformatics results. We evaluated histological pathologies, inflammatory response, intestinal barrier function, ferroptosis markers, and apoptosis regulators.

RESULTS

Celecoxib treatment significantly ameliorated DSS-induced UC in mice, as evidenced by the body weight change curve, colon length change curve, disease activity index (DAI) score, and histological index score. Celecoxib treatment reduced the level of pro-inflammatory factors and promoted the expressions of intestinal tight junction proteins such as Claudin-1 and Occludin, thereby restoring the integrity of the intestinal mucosal barrier. Furthermore, celecoxib treatment reversed the ferroptosis characteristics in DSS-induced mice by increasing glutathione (GSH), decreasing malondialdehyde (MDA), and increasing the expression of GPX-4 and xCT. Additionally, apoptosis was induced in mice with UC, as evidenced by increased Caspase3, BAD, P53, BAX, Caspase9 and Aifm1 production, and decreased expression of BCL-XL and BCL2. Celecoxib treatment significantly reversed the apoptotic changes in DSS-induced mice.

CONCLUSION

Our findings suggest that celecoxib effectively treats DSS-induced UC in mice by inhibiting ferroptosis and apoptosis.

A Systematic Review of the Effectiveness of Non-Pharmacological Therapies Used by Nurses in Children Undergoing Surgery

OBJECTIVE

The aim of this study was to identify non-pharmacological pain relief therapies in children undergoing surgery.

DESIGN AND DATA SOURCES

Using keywords extracted from Medical Subject Headings and "Descriptores en Ciencias de la Salud" we searched for articles in the Web of Science, Scopus, Cuiden, PubMed, and CINHAL databases from the last five years, and performed a reverse search. We assessed the documentary quality of the articles using various standardized instruments.

RESULTS

The final review included eleven studies. In terms of cognitive-behavioral techniques, there is evidence that both music and video therapy are effective in reducing postoperative pain in children in seven studies, and therapeutic play in five studies. Other methods used less frequently but found to be effective included laughter therapy in one study and deep breathing in another. Regarding physical methods of pain relief, massage was found to be an effective non-pharmacological therapy for reducing pediatric postoperative pain in two studies and ineffective in another.

CONCLUSIONS

In this study, we highlight the importance of non-pharmacological therapies in pediatric postoperative pain management. Cognitive-behavioral techniques, especially music therapy, video therapy, and therapeutic play, reduce pediatric postoperative pain. They are therefore effective therapies that nurses can use in this area. Further research into the effectiveness of storytelling is necessary, as the evidence is not entirely conclusive. More evidence is also needed on physical methods of pain relief, particularly massage.

Health Insurance Mandates for Nonpharmacological Pain Treatments in 7 US States

This cross-sectional study examines the extent to which states have introduced or enacted mandates for coverage of nonpharmacological pain treatments and characterizes the variation in such mandates.

Back Pain in the Era of Opioid Restriction and Implications for Neurosurgeons Based on Qualitative Findings From a Rural State

Historically, back pain has been an inciting complaint for the initiation of opioids. Aggressive marketing of opioids to treat back pain coupled with the initiation of pain being treated as "the fifth vital sign" contributed to the emerging opioid crisis in the USA. West Virginia (WV) has long been considered the epicenter of the crisis. In 2018, the WV legislature passed a bill that placed prescribing limits on opioids. Our group set out to investigate the impacts of opioid prescribing restrictions through a sequential, mixed methods study evaluating prescription trends and stakeholder experiences. These stakeholder experiences generated emergent themes regarding the evolution of the opioid crisis up to and beyond the implementation of the bill, which is of relevance to neurosurgeons and back pain treatment. This study explores those findings for a neurosurgical audience. This study consisted of open-ended, semi-structured interviews with a purposive sample of 50 physicians, pharmacists, and patients in WV. Interviews were recorded and transcribed verbatim. Content analysis was utilized as the methodological orientation. Five theoretical domains relevant to the treatment of back pain emerged, describing the prevalence of opioid use, barriers to access care, the importance of opioids for function in resource-poor rural areas, disconnected and siloed care, and patient views on the impacts of pain care gaps and solutions. Spinal pain care in rural WV is complex due to identified challenges. Care siloing factors in suboptimal spinal pain care. Future work should define, implement, and assess the real-world effectiveness of treatment paradigms for the full spectrum of surgical and non-surgical back pain complaints. Neurosurgeons should be present in this arena.

Efficacy of chronic neck pain self-treatment using press needles: a randomized controlled clinical trial

Background

Chronic neck pain is common among Japanese individuals, but few receive treatment. This randomized controlled trial aimed to evaluate the efficacy of acupuncture using press needles in the self-treatment of chronic neck pain and preliminarily identify the characteristics of patients likely to benefit from this treatment.

Methods

Fifty participants with chronic neck pain were allocated to receive either press needle or placebo treatment for 3 weeks. The visual analogue scale (VAS) and motion-related VAS (M-VAS) scores for neck pain, Neck Disability Index score, and pressure pain threshold were measured at baseline, after the first session, at the end of the last session, and 1 week after the last session. Changes in the outcomes were analyzed using analysis of variance, and the relationships between the variables were evaluated using structural equation modeling.

Results

Intervention results as assessed by VAS score revealed no significant differences in the ANOVA. A between-groups comparison of M-VAS scores at the end of the last session and baseline showed a significant difference (press needle: -21.64 ± 4.47, placebo: -8.09 ± 3.81, p = 0.025, d = -0.65). Structural equation modeling revealed a significant pain-reducing effect of press needle treatment (β = -0.228, p = 0.049). Severity directly affected efficacy (β = -0.881, p < 0.001). Pain duration, baseline VAS and Neck Disability Index scores were variables explaining severity, while age and occupational computer use were factors affecting severity.

Conclusion

Self-treatment with press needles for chronic neck pain did not significantly reduce the VAS score compared to placebo but reduced the motion-related pain as assessed by M-VAS score. A direct association was observed between pain severity and the effectiveness of press needles, and the impact of age and computer were indirectly linked by pain severity.

Clinical Trial Registration

Identifier UMIN-CTR, UMIN000044078.

The Multisystem effects of Long COVID Syndrome and Potential Benefits of Massage Therapy in Long COVID Care

Background

A major complication of infection with Severe Acute Respiratory Coronavirus 2 (SARS-CoV-2), the virus responsible for COVID-19, is the potential for Long COVID Syndrome. While the pathophysiology of Long COVID Syndrome has yet to be described, the disease presentation is characterized by long-term symptoms with debilitating effects on human health. A better understanding of Long COVID symptomology may open up new avenues for patient treatment such as massage therapy.

Methods

From the PubMed database, cohort studies that examined post-infection COVID sequelae published between January 1st, 2021 and April 30th, 2021 were selected to investigate patient demographics and symptoms. A review of massage therapy literature since 2000 in conjunction with identified Long COVID symptoms was performed.

Results

This systematic review identified 17 cohort studies across the world that investigated the symptomatology of patients suffering from post-COVID sequelae in multiple organ systems. We identified the pulmonary and nervous systems to be the organ systems most affected with post-COVID sequelae, with PTSD, fatigue, dyspnea, cough, sleep disturbances, loss of smell, abdominal pain, and decreased appetite as the most common symptoms reported by >20% of Long COVID patients. Massage therapy was historically found to provide benefits to patients experiencing similar symptoms to those identified in Long COVID.

Conclusions

Recognizing the need for new approaches to treatment for Long COVID Syndrome, we identify massage therapy as a potential therapeutic treatment to positively impact the organ systems affected by Long COVID, especially the high-incident symptoms, and improve patient quality of life.

Treatment Goals and Preferences of Black Veterans with Chronic Musculoskeletal Pain

Understanding patient goals and preferences is critical in the context of complex conditions such as chronic pain. This need may be especially pronounced for Black patients, who experience significant health and healthcare disparities. The primary aim of this study was to describe the treatment goals and preferences of Black veterans with chronic musculoskeletal pain who were enrolled in the intervention arm of a randomized controlled trial testing a coaching intervention. In the coaching sessions, participants (n = 106) identified their most important pain-related treatment goals and preferences. Participants' top treatment goals were to improve physical functioning (61%), increase engagement in valued activities (45%), and reduce pain intensity (37%). Most participants (73%) preferred non-pharmacological treatments (eg, physical therapy, exercise, acupuncture, yoga). The 17% of participants who identified medications as a preferred treatment demonstrated higher levels of depression and anxiety compared to those who did not. Approximately 42% and 21% of participants stated a preference to avoid pharmacological and surgical pain treatments, respectively. Black patients with chronic pain prioritize improving physical functioning and pain intensity in service of increasing their engagement in exercise, work, relationships, and leisure activities. Also, in the current study, patients expressed a clear preference for non-pharmacological pain treatments. Future research should investigate ways to improve communication of goals and preferences with providers and facilitate access to non-pharmacological treatments for Black patients with chronic pain. PERSPECTIVE: This article describes the treatment goals and preferences of Black veterans with chronic pain. Most patients prioritized goals to improve physical functioning, pain severity, and participation in valued activities. Patients primarily preferred non-pharmacological treatments. This emphasizes the need for clear communication with Black patients regarding pain-related goals and non-pharmacological treatment options.

Communication and activation in pain to enhance relationships and treat pain with equity (COOPERATE): a randomized clinical trial

ABSTRACT

Racialized disparities in chronic pain care are well-documented and persist despite national priorities focused on health equity. Similar disparities have been observed in patient activation (ie, having the knowledge, confidence, and skills to manage one's health). As such, interventions targeting patient activation represent a novel approach to addressing and reducing disparities in pain care. Communication and Activation in Pain to Enhance Relationships and Treat Pain with Equity is a randomized controlled trial of a 6-session telephone-delivered intervention to increase patient activation for Black patients with chronic pain. Two hundred fifty Black patients from a Midwestern Veterans Affairs medical center were randomized to the intervention or attention control. The primary outcome was patient activation; secondary outcomes included communication self-efficacy, pain, and psychological functioning. Outcomes were assessed at baseline and at 3 (primary endpoint), 6, and 9 months (sustained effects). Analyses used an intent-to-treat approach. Compared with baseline, patient activation increased 4.6 points at 3 months (versus +0.13 in control group, 95% CI: 0.48, 7.34; P = 0.03). These improvements in the intervention group were sustained, with +7 from baseline at 6 months and +5.77 at 9 months, and remained statistically significant from the control group. Communication self-efficacy increased significantly relative to the control group from baseline to 3 months. Pain intensity and interference improved at 3 months, but differences were not significant after adjusting for multiple comparisons. Most other secondary outcomes improved, but group differences were not statistically significant after controlling for multiple comparisons. Results suggest that increasing patient activation is a potentially fruitful path toward improving pain management and achieving health equity.

Engagement in Integrative and Nonpharmacologic Pain Management Modalities Among Adults with Chronic Pain: Analysis of the 2019 National Health Interview Survey

Objective

To examine variables associated with engagement in (1) integrative health and medicine (IHM) and (2) nonpharmacologic modalities rather than opioids among United States adults with chronic pain.

Methods

Using the 2019 National Health Interview Survey, we examined sociodemographic, pain, and mental health predictors of (1) the sum of IHM modalities (ie, chiropractic care, yoga/Tai Chi, massage, or meditation/guided imagery) used to manage pain and (2) exclusive engagement in nonpharmacologic pain management modalities (ie, IHM, a chronic pain self-management program, support groups, or physical, rehabilitative, occupational, or talk therapy) or opioids in the past 3 months.

Results

Metropolitan residency, higher family income, higher education levels, increased number of pain locations, and increased frequency of pain limiting life/work activities were associated with increased odds of IHM engagement. Older age, male sex, non-Hispanic Black/African American race/ethnicity, and daily opioid use were associated with decreased odds of IHM engagement. Older age, male sex, and increased depressive symptoms were associated with decreases in the count of IHM modalities used to manage pain. Metropolitan residency, higher family income, and higher education levels were associated with increased odds of exclusive nonpharmacologic modality engagement. Older age and increasing frequency of pain limiting life/work activities were associated with decreased odds of exclusive nonpharmacologic modality engagement.

Conclusions

We identified several contrasts between factors prevalent among individuals with chronic pain and factors associated with engagement in nonpharmacologic and IHM modalities. These results support efforts to address barriers to accessing these modalities among subpopulations of adults with chronic pain (eg, older adults, individuals identifying as Black/African American, rural residents, and those with lower levels of education and income).

Multimodal Approaches in the Treatment of Chronic Peripheral Neuropathy-Evidence from Germany

Patients with chronic peripheral neuropathy suffer greatly and their quality of life is often restricted. Drug therapy can be accompanied by undesirable side effects and intolerances, or the hoped-for effect does not materialize. Therefore, in addition to drug therapy, attempts are also made to treat the physical symptoms with complementary procedures. In the case of severe forms, the search for a suitable form of therapy is difficult. Complex treatments can be an innovative way to treat peripheral neuropathy. At the same time, several different therapy methods are carried out at high frequency by a specialized treatment team. This study aimed to provide an overview of possible complementary forms of therapy. The focus was on a comparison of two interdisciplinary complex therapies that are used in severe cases in an acute inpatient care setting in Germany. The six dimensions (energy, sleep, pain, physicality, emotional response and social isolation) of the Nottingham Health Profile (NHP) were used to assess quality of life. Both complex treatments (naturopathic complex therapy/multimodal pain therapy) showed a significant reduction in impairment in all dimensions of the NHP. In addition, a multivariate analysis was carried out to take into account several influencing variables at the same time. At the time of admission to the hospital, the degree of chronicity was recorded for each patient. This allowed statements to be made about the effect of the respective therapy depending on the chronification stage of the patient. It has been shown that patients with acutely exacerbated pain with the highest degree of chronicity also benefit from both complex treatments. The naturopathic complex treatment gives the treatment team more options. Aspects such as nutrition, methods from phytotherapy and traditional Chinese medicine can be integrated into inpatient care. Thus, a patient-centered, holistic therapy can take place. However, an interdisciplinary holistic therapy requires more time for both the practitioner and the patient. This should be taken into account in the health systems in the context of the diagnosis related groups.

Acute Perioperative Pain Management of the Orthopaedic Patient: Guidance for Operationalizing Evidence Into Practice

Orthopaedic surgery often results in pain, with less than half of patients reporting adequate relief. Unrelieved acute pain occurring after surgery increases the risk of negative sequelae, including delayed healing, increased morbidity, pulmonary complications, limited rehabilitation participation, anxiety, depression, increased length of stay, prolonged duration of opioid use, and the development of chronic pain. Interventions that are individualized, evidence-informed, and applied within an ethical framework improve healthcare delivery for patients, clinicians, and healthcare organizations. Recommendations for using the principles of effective pain management from preoperative assessment through discharge are detailed, including recommendations for addressing barriers and challenges in applying these principles into clinical practice.

Current Evidence-based Approaches to Multimodal Pain Control and Opioid Minimization After Arthroscopic and Knee Preservation Surgery

Nonarthroplasty knee procedures are common and may cause a wide spectrum of postoperative pain, ranging from minimal to severe, depending on the patient, pathology, and procedure. Procedures include ligament repair and reconstruction, especially anterior cruciate ligament reconstruction, meniscal débridement, repair and transplant, periarticular osteotomy, and cartilage restoration. Multimodal analgesia regimens have been implemented successfully, but notable variation characterizes current protocols. Increased public and physician awareness of the burden of opioid usage in the United States has encouraged the medical community to embrace opioid-minimizing and nonopioid techniques to mitigate the deleterious effects of these medications. Nonopioid medications; anesthesia techniques; surgical techniques; and postoperative nonmedication strategies, including physical therapy, transcutaneous electrical nerve stimulation, cryotherapy, cognitive techniques, and non-Western interventions, can form part of an effective multimodal approach. A multimodal approach can facilitate adequate analgesia without compromising patient satisfaction or outcome.

Massage-like stroking produces analgesia in mice

Chronic pain treatment remains a major challenge and pharmacological interventions are associated with important side effects. Manual medicine treatments such as massage, acupuncture, manipulation of the fascial system (MFS), and osteopathic manipulative treatments produce pain relief in humans, but the underlying mechanism is poorly understood limiting leverage and optimization of manual medicine techniques as safe pain therapy. To decipher the physiological mechanisms of manipulative medicine treatments, we have established a preclinical model. Here, we established a murine model of massage-like stroking (MLS)-induced analgesia. We characterized that the analgesia effects were present in both sexes, and were independent of the experimenters, handling, consciousness, and opioid receptors. MLS alleviates thermal pain in naive mice and postoperative pain hypersensitivity. This novel model will allow discovery of the physiological mechanisms involved in MLS-induced analgesia and identification of new therapeutic strategies.

Immediate Effects of Integrative Health and Medicine Modalities Among Outpatients With Moderate-To-Severe Symptoms

Background

Patients seeking integrative health and medicine (IHM) modalities often present with multiple physical and psychological concerns. Research supports IHM's effectiveness for addressing symptoms over longer time periods. However, few studies have evaluated immediate outpatient effects.

Objective

This study describes pre-encounter patient-reported outcome (PRO) clusters and examines the immediate clinical effectiveness of IHM modalities on pain, stress, and anxiety among outpatients with moderate-to-severe symptoms.

Methods

A retrospective review was conducted of encounters among adults presenting to outpatient acupuncture, chiropractic, massage, integrative medicine consultation, or osteopathic manipulation treatment between January 2019 and July 2020. Encounters were included if patients reported pre-encounter pain, stress, or anxiety ≥4 on a numeric rating scale (NRS). Outcome analyses included random effects for patient and provider using a mixed model.

Results

Across 7335 clinical encounters among 2530 unique patients (mean age: 49.14 years; 81.0% female; 75.9% White; 15.8% Black/African American), the most common pre-encounter PRO clusters were pain, stress, and anxiety ≥4 (32.4%); pain ≥4 only (31.3%); and stress and anxiety ≥4 (15.6%). Clinically meaningful single-encounter mean [95% CI] changes were observed across all modalities in pain (-2.50 [-2.83, -2.17]), stress (-3.22 [-3.62, -2.82]), and anxiety (-3.05 [-3.37, -2.73]).

Conclusion

Patients presenting to outpatient IHM with moderate-to-severe symptoms most often presented with pain, stress, and anxiety ≥4 on the NRS. Multiple IHM modalities yielded clinically meaningful (≥2 unit) immediate reductions in these symptoms. Future research measuring immediate and longitudinal effectiveness is needed to optimize the triage and coordination of IHM modalities to meet patients' needs.

Mapping Evidence-Based Non-Opioid and Non-Pharmacological Pain Management Modalities Across Minnesota: The Non-Opioid Pain Alleviation Information Network Project

Objective: The Non-Opioid Pain Alleviation Information Network (NOPAINMN) project was designed to identify, consolidate, and map evidence-based non-opioid and non-pharmacological pain management complementary and integrative health (CIH) modalities for chronic pain management across Minnesota into a searchable and informational website (www.nopainmn.org). Methods: The Academic Consortium for Integrative Medicine & Health's Pain Task Force White Paper identifying evidence-based research of non-pharmacological pain practice (NPPC) was reviewed and referenced. National and state certifying boards and accrediting organizations for NPPC modalities were accessed to identify Minnesota-based NPPC providers' name, business/health-system affiliation, address, contact information, and credentials. The NOPAINMN website displays these data in a consumer-facing website with searchable fields such as NPPC modality type, and location with varying distances. The website was β-tested by practitioners and stakeholders for optimization. Eight main NPPC modalities and their respective subcategories were identified and mapped: Acupuncture; Integrative Medical Care (Functional medicine consultation and Integrative medicine consultation); Massage Therapy; Mind-Body Therapies (Biofeedback, Clinical Hypnosis, Mindfulness-Based Stress Reduction, and Music Therapy); Movement Therapies (Tai Chi, qigong, and Yoga Therapy); Psychology (Cognitive Behavioral Therapy); Rehabilitative Therapies (Physical and Occupational Therapy); and Spinal Manipulation. Results: All information compiled resulted in 17,155 providers/practitioners. Physical Therapy had the greatest number of reported providers (n = 5224), followed by Occupational Therapy (n = 3792), Psychology (n = 3324), Chiropractic (n = 3033), Acupuncture (n = 591), and Massage Therapy (n = 544). The Resource Map included 56 major health systems, 686 facilities, 2651 solo or private group practices, and 14 academic training schools. With web-based cross-referencing, providers and facilities were affiliated and linked with health systems to produce an interconnected mapping system. β-Testing with patients found that the website was reported as relatively easy to use and informative. Conclusion: The website was created to assist individuals, health care providers, insurance carriers, and health care facilities in finding evidence-based information and resources on NPPC to guide, support, and proactively manage and engage chronic pain patients across Minnesota.

Different Outcomes According to Needling Point Location Used in Sham Acupuncture for Cancer-Related Pain: A Systematic Review and Network Meta-Analysis

Numerous acupuncture studies have been conducted on cancer-related pain; however, its efficacy compared to sham acupuncture remains controversial. We confirmed whether the outcome of acupuncture differs according to the needling points of sham acupuncture for cancer-related pain. We searched 10 databases on 23 May 2023 to screen acupuncture trials using sham acupuncture or waiting list as controls for cancer-related pain. Sham acupuncture was classified into two types, depending on whether the needling was applied at the same locations as verum acupuncture (SATV) or not (SATS). A network meta-analysis (NMA) was performed on the basis of a frequentist approach to assess pain severity. Eight studies (n = 574 participants) were included in the review, seven of which (n = 527 participants) were included in the NMA. The pain severity was not significantly different between SATV and verum acupuncture, but verum acupuncture significantly improved pain severity compared to SATS. The risk of bias affecting the comparisons between the verum and sham acupuncture was generally low. Previous acupuncture trials for cancer-related pain showed differing outcomes of sham and verum acupuncture, depending on the needling points of sham acupuncture. The application of SATV cannot be considered a true placebo, which leads to an underestimation of the efficacy of verum acupuncture.

Top Ten Tips Palliative Care Clinicians Should Know About Integrative Palliative Care

Integrative medicine (IM) use is widespread among individuals living with serious illness. There is a natural alignment between the fields of IM and palliative care (PC) rooted in their shared core values. Integrative palliative care (IPC) is an emerging focus within the field of PC that aims to broaden the healing toolkit available to patients with serious illness by combining standard-of-care biomedical treatments with evidence-informed integrative and complementary medicine practices with the goal of enhancing quality of life at every stage of a person's health journey. This article is an evidence-based guide to incorporating IPC practices into the care of seriously ill individuals.

Measures of sleep are not routinely captured in trials assessing treatment outcomes in knee osteoarthritis - A scoping systematic review and call to action

Objective

To identify and map the extent to which trials for pain interventions in individuals with knee osteoarthritis (OA) track measures of sleep, characterize the type of sleep measure assessed, and assess their influence on pain-related effect sizes.

Design

A scoping review was conducted, searching seven bibliometric databases from 2000 to 2022. We included all randomized controlled trials with a primary purpose of assessing non-surgical pain management interventions for adults with knee OA. All non-surgical interventions and any comparator or control were included. Demographic data were pooled from all trials.

Results

926 trials conducted in 61 countries met eligibility. Nineteen trials (2.1%) recorded some form of sleep assessment. Eleven trials (1.2%) assessed a formal index of sleep disturbance collected at multiple time points. No trials formally assessed the influence of sleep on the primary pain outcome (e.g., as a potential mediator), nor met the most recent guidelines for core data element recommendations regarding sleep assessment.

Conclusion

This review highlights the paucity of sleep data captured and reported in randomized controlled trials for knee OA. The vast majority of trials addressing symptomatic knee OA do not capture sleep measures, significantly limiting the ability to accurately determine an intervention's effect on pain. Future research should include formal sleep-centric assessments measured at multiple time points to analyze sleep dysfunction and its relationship on treatment effects.

The effectiveness and safety of non-pharmacological intervention for pain management in Parkinson's disease: A systematic review

Chronic pain is a non-motor symptom affecting from 60 to 80% of patients with Parkinson's disease (PD). PD patients can suffer from different types of pain, either specific or not specific of the disease, and depending on various pathophysiological mechanisms (nociceptive, nociplastic or neuropathic), which can be present at any stage of the disease. Non-pharmacological interventions (NPIs) are essential to complement routine care interventions in PD pain management. Moreover, in the literature, it has been shown that 42% of PD patients are already using complementary therapies. Hence, our aim was to investigate the effectiveness and safety of NPIs for pain management in PD. A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Eighteen published randomized control trials (RCTs) were included between 2004 and 2021 leading to a total of 976 PD patients. From them, we reported fifteen different NPIs classified in seven categories: physical exercises, balneotherapy, manual therapy, acupuncture, botanical preparation, body-psychological practice and multiprotection care. Our results have shown that NPIs for PD pain management had a low-to-moderate level of evidence showing mainly favourable results, even if some NPIs presented inconclusive results. Moreover, our review highlighted the clinical relevance of some specific NPIs in PD pain management: NPIs consisting of active physical activities, opposed to passive activities. The safety of NPIs was also confirmed since only few minor transient adverse events were reported. Nevertheless, even if some interesting results were found, the methodology of future studies needs to be more robust and to include comprehensive descriptions in order to offer reliable and sound recommendations to clinicians.

Integrative medical group visits for patients with chronic pain: results of a pilot single-site hybrid implementation-effectiveness feasibility study

Background

Approximately 20% of adults in the United States experience chronic pain. Integrative Medical Group Visit (IMGV) offers an innovative approach to chronic pain management through training in mindfulness, nutrition, and other mind-body techniques combined with peer support. To date, there are no studies on IMGV implementation, despite its promise as a feasible non-pharmacological intervention for chronic pain management. In this study, we assessed the feasibility of implementing IMGV and assessing its effectiveness for chronic pain.

Methods

Implementation Mapping was used to develop and evaluate implementation strategies for IMGV. Strategies included disseminating educational materials, conducting ongoing training, and conducting educational meetings. IMGV was delivered by three healthcare providers: an allopathic physician, registered yoga teacher, and naturopathic physician. The effectiveness of IMGV on patient health outcomes was assessed through qualitative interviews and a Patient-Reported Outcomes Scale (PROMIS-29). Provider perspectives of acceptability, appropriateness, and feasibility were assessed through periodic reflections (group interviews reflecting on the process of implementation) and field notes. Paired t-tests were used to assess changes between scores at baseline and post intervention. Qualitative data were coded by three experienced qualitative researchers using thematic content analysis.

Results

Of the initial 16 patients enrolled in research, 12 completed at least two sessions of the IMGV. Other than fatigue, there was no statistically significant difference between the pre- and post-scores. Patients reported high satisfaction with IMGV, noting the development of new skills for self-care and the supportive community of peers. Themes from patient interviews and periodic reflections included the feasibility of virtual delivery, patient perspectives on acceptability, provider perspectives of feasibility and acceptability, ease of recruitment, complexity of referral and scheduling process, balancing medical check-in with group engagement, and nursing staff availability.

Conclusions

IMGV was feasible, acceptable, and effective from the perspectives of patients and providers. Although statistically significant differences were not observed for most PROMIS measures, qualitative results suggested that participants experienced increased social support and increased pain coping skills. Providers found implementation strategies effective, except for engaging nurses, due to staff being overwhelmed from the pandemic. Lessons learned from this pilot study can inform future research on implementation of IMGV.

Racial and Ethnic Differences in Receipt of Nonpharmacologic Care for Chronic Low Back Pain Among Medicare Beneficiaries With OUD

Importance

Nonpharmacologic treatments are important for managing chronic pain among persons with opioid use disorder (OUD), for whom opioid and other pharmacologic therapies may be particularly harmful. Racial and ethnic minority individuals with chronic pain and OUD are vulnerable to suboptimal pain management due to systemic inequities and structural racism, highlighting the need to understand their receipt of guideline-recommended nonpharmacologic pain therapies, including physical therapy (PT) and chiropractic care.

Objective

To assess differences across racial and ethnic groups in receipt of PT or chiropractic care for chronic low back pain (CLBP) among persons with comorbid OUD.

Design, Setting, and Participants

This retrospective cohort study used a 20% random sample of national Medicare administrative data from January 1, 2016, to December 31, 2018, to identify fee-for-service community-dwelling beneficiaries with a new episode of CLBP and comorbid OUD. Data were analyzed from March 1, 2022, to July 30, 2023.

Exposures

Race and ethnicity as a social construct, categorized as American Indian or Alaska Native, Asian or Pacific Islander, Black or African American, Hispanic, non-Hispanic White, and unknown or other.

Main Outcomes and Measures

The main outcomes were receipt of PT or chiropractic care within 3 months of CLBP diagnosis. The time (in days) to receiving these treatments was also assessed.

Results

Among 69 362 Medicare beneficiaries analyzed, the median age was 60.0 years (IQR, 51.5-68.7 years) and 42 042 (60.6%) were female. A total of 745 beneficiaries (1.1%) were American Indian or Alaska Native; 444 (0.6%), Asian or Pacific Islander; 9822 (14.2%), Black or African American; 4124 (5.9%), Hispanic; 53 377 (77.0%); non-Hispanic White; and 850 (1.2%), other or unknown race. Of all beneficiaries, 7104 (10.2%) received any PT or chiropractic care 3 months after a new CLBP episode. After adjustment, Black or African American (adjusted odds ratio, 0.46; 95% CI, 0.39-0.55) and Hispanic (adjusted odds ratio, 0.54; 95% CI, 0.43-0.67) persons had lower odds of receiving chiropractic care within 3 months of CLBP diagnosis compared with non-Hispanic White persons. Median time to chiropractic care was longest for American Indian or Alaska Native (median, 8.5 days [IQR, 0-44.0 days]) and Black or African American (median, 7.0 days [IQR, 0-42.0 days]) persons and shortest for Asian or Pacific Islander persons (median, 0 days [IQR, 0-6.0 days]). No significant racial and ethnic differences were observed for PT.

Conclusions and Relevance

In this retrospective cohort study of Medicare beneficiaries with comorbid CLBP and OUD, receipt of PT and chiropractic care was low overall and lower across most racial and ethnic minority groups compared with non-Hispanic White persons. The findings underscore the need to address inequities in guideline-concordant pain management, particularly among Black or African American and Hispanic persons with OUD.

Pain Management in the Postoperative Period for People With Dementia: An Integrative Review

Objective

With the increased global prevalence of older people with dementia, more will present for surgery over the coming decades. Therefore, the objective of this study was to synthesize the existing research about how pain in managed for people with dementia in the postoperative period and discuss the implications for clinical practice.

Methods

For this integrative review, the Cumulative Index to Nursing and Allied Health literature, Medline/Pubmed, ProQuest, ERIC, and Health Source Nursing were searched to identify original empirical research published between 2000 and 2021. Tasks were divided between reviewers to ensure independent study selection, data extraction, and risk of bias assessment.

Results

Eleven articles were eligible. The evidence is incompletely developed therefore the review focused on pain assessment, the types and amount of pain relief, that people with dementia receive less analgesia than people without dementia and the challenges for effective pain management. Most studies were surgery for hip fracture so there is scope to look at outcomes for other types of surgery. Analgesia was administered but it was noted that even over a 20-year period, people with dementia received less than cognitively intact people. Pain management could have a stronger evidence-base with more psychometric development of pain assessment tools. Challenges are due to the impaired ability of the person with dementia to communicate pain and that clinicians have difficulty understanding pain behavior in people with dementia.

Conclusion

Adequate pain management for people with dementia in the postoperative period is important for a faster and better recovery.

Pain Management in the Elderly: A Narrative Review

With the increase in life expectancy in the United States, octogenarians and nonagenarians are more frequently seen in clinical practice. The elderly patients have multiple preexisting comorbidities and are on multiple medications, which can make pain management complex. Moreover, the elderly population often suffers from chronic pain related to degenerative processes, making medical management challenging. In this review, the authors collated available evidence for best practices for pain management in the elderly.

Symptom Management in the Older Adult: 2023 Update

In the older adult with a serious illness, the goal of palliative medicine and symptom management is to optimize quality of life. Frailty has become an overarching finding in many older adults with serious illness. Symptom management options need to be considered in the lens of increasing frailty along an illness trajectory. Here, the authors emphasize literature updates and best practices for the most common symptoms experienced by the older adult with a serious illness.

Optimizing Patient-Reported Outcome Collection and Documentation in Medical Music Therapy: Process-Improvement Study

BACKGROUND

To measure the effectiveness of nonpharmacologic interventions delivered during clinical care, investigators need to ensure robust and routine data collection without disrupting individualized patient care or adding unnecessary documentation burden.

OBJECTIVE

A process-improvement study was undertaken to improve documentation consistency and increase the capture of patient-reported outcomes (PROs; ie, stress, pain, anxiety, and coping) within a medical music therapy (MT) team.

METHODS

We used 2 Plan-Do-Study-Act (PDSA) cycles to improve documentation processes among an MT team (13.3 clinical full-time equivalent staff). Trainings focused on providing skills and resources for optimizing pre- and postsession PRO collection, specific guidelines for entering session data in the electronic health record, and opportunities for the team to provide feedback. Two comparisons of therapists' PRO collection rates were conducted: (1) between the 6 months before PDSA Cycle 1 (T0) and PDSA Cycle 1 (T1), and (2) between T1 and PDSA Cycle 2 (T2).

RESULTS

Music therapists' rates of capturing any PRO within MT sessions increased significantly (P<.001) from T0 to T1 and from T1 to T2 for all domains, including stress (4/2758, 0.1% at T0; 1012/2786, 36.3% at T1; and 393/775, 50.7% at T2), pain (820/2758, 29.7% at T0; 1444/2786, 51.8% at T1; and 476/775, 61.4% at T2), anxiety (499/2758, 18.1% at T0; 950/2786, 34.1% at T1; and 400/775, 51.6% at T2), and coping (0/2758, 0% at T0; 571/2786, 20.5% at T1; and 319/775, 41.2% at T2). Music therapists' feedback and findings from a retrospective analysis were used to create an improved electronic health record documentation template.

CONCLUSIONS

Rates of PRO data collection improved within the medical MT team. Although the process improvement in this study was applied to a nonpharmacologic MT intervention, the principles are applicable to numerous inpatient clinical providers. As hospitals continue to implement nonpharmacologic therapies in response to the Joint Commission's recommendations, routine PRO collection will provide future researchers with the ability to evaluate the impact of these therapies on pain relief and opioid use.

Association between early nonpharmacological management and follow-up for low back pain in the veterans health administration

Background

Low back pain (LBP) is a common reason individuals seek healthcare. Nonpharmacologic management (NPM) is often recommended as a primary intervention, and earlier use of NPM for LBP shows positive clinical outcomes. Our purpose was to evaluate how timing of engagement in NPM for LBP affects downstream LBP visits during the first year.

Methods

This study was a secondary analysis of an observational cohort study of national electronic health record data. Patients entering the Musculoskeletal Diagnosis/Complementary and Integrative Health Cohort with LBP from October 1, 2016 to September 30, 2017 were included. Exclusive patient groups were defined by engagement in NPM within 30 days of entry ("very early NPM"), between 31 and 90 days ("early NPM"), or not within the first 90 days ("no NPM"). The outcome was time, in days, to the final LBP follow-up after 90 days and within the first year. Cox proportional hazards regression was used to model time to final follow up, controlling for additional demographic and clinical covariables.

Results

The study population included 44,175 patients, with 16.7% engaging in very early NPM and 13.1% in early NPM. Patients with very early NPM (5.2 visits, SD=4.5) or early NPM (5.7 visits, SD=4.6) had a higher mean number of LBP visits within the first year than those not receiving NPM in the first 90 days (3.2 visits, SD = 2.5). The very early NPM (HR=1.50, 95% CI: 1.46-1.54; median=48 days, IQR=97) and early NPM (HR=1.27, 95% CI: 1.23-1.30; median=88 days, IQR=92) had a significantly shorter time to final follow-up than the no NPM group (median=109 days, IQR=150).

Conclusions

Veterans Health Administration patients receiving NPM for LBP within the first 90 days after initially seeking care demonstrate a significantly faster time to final follow-up visit within the first year compared to those who do not.

Effectiveness of music therapy within community hospitals: an EMMPIRE retrospective study

Introduction

Given the challenges health systems face in providing effective nonpharmacologic treatment for pain and psychological distress, clinical effectiveness studies of evidence-based strategies such as music therapy (MT) are needed.

Objectives

This study examined changes in patient-reported outcomes (PROs) after MT and explored variables associated with pain reduction of ≥2 units on a 0 to 10 numeric rating scale (NRS).

Methods

A retrospective review was conducted on initial MT interventions provided to adults receiving community hospital care between January 2017 and July 2020. Sessions were included if participants reported pre-session pain, anxiety, and/or stress scores of ≥4 on the NRS. Data analysis included a bootstrap analysis of single-session changes in PROs and a logistic regression exploring variables associated with pain reduction (ie, ≥2 units vs <2 units).

Results

Patients (n = 1056; mean age: 63.83 years; 76.1% female; 57.1% White; 41.1% Black/African American) reported clinically significant mean reductions in pain (2.04 units), anxiety (2.80 units), and stress (3.48 units). After adjusting for demographic, clinical, and operational characteristics in the model (c-statistic = 0.668), patients receiving an MT session in which pain management was a goal were 4.32 times more likely (95% confidence interval 2.26, 8.66) to report pain reduction of ≥2 units than patients receiving an MT session in which pain management was not a session goal.

Conclusion

This retrospective study supports the clinical effectiveness of MT for symptom management in community hospitals. However, additional research is needed to determine which characteristics of MT interventions and patients influence pain change.

Massage therapy for children, adolescents, and young adults: Clinical delivery and effectiveness in hematology and oncology

BACKGROUND

Children, adolescents, and young adults with hematologic and/or oncologic conditions experience multiple, significant symptoms (e.g., pain, stress, and anxiety), which may be addressed by nonpharmacologic approaches such as massage therapy (MT). The purpose of this study was to describe the clinical delivery of MT provided by a certified pediatric massage therapist and assess effectiveness in two patient groups: those with sickle cell disease (SCD) or hematologic and/or oncologic conditions excluding SCD (HemOnc).

METHODS

Investigators conducted a retrospective review of MT sessions provided to patients 0-39 years with hematologic and/or oncologic conditions at a large pediatric academic medical center.

RESULTS

Between October 2019 and December 2021, 3015 MT sessions were provided to 243 patients (171 HemOnc; 72 SCD) and documented in the electronic health record. Patients (mean age: 12.21 ± 7.19 years) were generally White (49.4%) or Black/African American (43.2%), non-Hispanic (94.2%), and 52.3% female. Patients in the SCD group (vs. patients in the HemOnc group) reported significantly higher (p < .05) pretreatment pain (6.95 vs. 4.46), stress (6.47 vs. 4.58), and anxiety (6.67 vs. 4.59). All patients reported clinically and statistically significant (p < .001) mean reductions in pain (-2.25 ± 1.87), stress (-2.50 ± 1.73), and anxiety (-2.52 ± 1.69), with patients in the HemOnc group reporting greater mean pain change (-2.54 vs. -1.87) than patients in the SCD group.

CONCLUSIONS

This study supports the clinical effectiveness of MT for addressing acute pain, stress, and anxiety among youth with hematologic and/or oncologic conditions. Future research is needed to identify optimal MT utilization.

Pediatric-to-Adult Transfer of Care in Patients With Pancreas Disease: Recommendations for Care and Research Opportunities

Young adults who have experienced recurrent acute pancreatitis and chronic pancreatitis as children or adolescents are vulnerable to poor follow-up and disease management during the transfer from the pediatric to adult healthcare system. Although formalized transition programs for young adults have been developed and described for other disease conditions, no such program has been described for young adults with pancreatic disease. This document is the first expert opinion outlining the important aspects of a transitional care and transfer program tailored to youth with recurrent acute and chronic pancreatitis. We emphasize the unique needs of these patients as they transfer to adult health care and the need for further research. The goal of improved transitional care and transfer is to enhance the services provided to adolescents/young adults with pancreatic disease in both healthcare settings and improve continuity of follow-up care.

Factors associated with frequent or daily use of prescription opioids among adults with chronic pain in the United States

OBJECTIVES

We aimed to estimate utilization rates of prescription opioids among adults with chronic pain in the United States (US) and identify factors associated with the frequent or daily use of prescription opioids.

METHODS

This was a case-control analysis of the 2019 National Health Interview Survey of adults.

RESULTS

Over 50.2 million adults in the US reported chronic pain in the past 3 months, but only 10.5% of this group said they used prescription opioids frequently or daily to manage their pain. Adults with chronic pain were significantly more likely to use opioids if they had incomes below the federal poverty level (15.7%), relied on public health insurance (14.8%), had been hospitalized in the past year (17.8%), or rated their health as fair or poor (18.4%). The highest rates of opioid use were reported among adults with severe (24.4%) or moderate disability (18.9%).

CONCLUSIONS

Approximately 5.3 million adults use prescription opioids frequently or daily to manage chronic pain. These individuals should receive regular clinical assistance to manage their pain, including medication management and, when appropriate, referral to evidence-based treatment programs for opioid use disorder.

Analgesic and Anxiolytic Effects of Virtual Reality During Minor Procedures in an Emergency Department: A Randomized Controlled Study

STUDY OBJECTIVE

We aimed to assess the analgesic and anxiolytic efficacy of distraction, a nonpharmacologic intervention provided by 3-dimensional (3D) virtual reality (VR) compared with that provided by 2-dimensional (2D) VR during minor emergency department (ED) procedures.

METHODS

This randomized controlled study conducted in the ED of a teaching hospital included patients aged more than or equal to 18 years undergoing minor procedures. The patients watched the same computer-generated VR world either in 3D in a head-mounted display (intervention) or in 2D on a laptop screen (control). Our main outcomes were pain and anxiety during the procedure, assessed on a 100-mm visual analog scale. Secondary outcomes included the impression of telepresence in the computer-generated world assessed using the Igroup Presence Questionnaire, and the prevalence and intensity of cybersickness measured on a 100-mm visual analog scale.

RESULTS

The final analysis included 117 patients. The differences in median procedural pain and anxiety levels between the 2D and 3D VR groups were not significant: -3 mm (95% confidence interval [CI] -14 to 8) and -4 mm (95% CI -15 to 3), respectively; the difference in telepresence was 2.0 point (95% CI 0 to 2.0), and the proportion difference of cybersickness was -4% (95% CI -22 to 14), with an intensity difference of -5 mm (95% CI -9 to 3).

CONCLUSION

During minor procedures in adult patients in the ED, distraction by viewing a 3D virtual world in a head-mounted VR display did not result in lower average levels of procedural pain and anxiety than that by 2D viewing on a screen despite a higher sense of telepresence. There were no significant differences in the prevalence and intensity of cybersickness between the 2 groups.

Group Acupuncture Therapy With Yoga Therapy for Chronic Neck, Low Back, and Osteoarthritis Pain in Safety Net Settings for an Underserved Population: A Feasibility Pilot Study

Background

Acupuncture and yoga have both been shown to be effective in chronic pain. Underrepresented populations have poorer pain outcomes with less access to effective pain care.

Objective

To assess the feasibility of bundling group acupuncture with yoga therapy for chronic neck, back or osteoarthritis pain in safety net settings.

Methods

This was a feasibility pilot in Bronx and Harlem primary care community health centers. Participants with chronic neck, back or osteoarthritis pain received acupuncture and yoga therapy over a 10-week period. Participants received 10 weekly acupuncture treatments in group setting; with Yoga therapy sessions beginning immediately following the 3rd session. Primary outcome was pain interference and pain intensity on the Brief Pain Inventory (BPI); Outcomes were measured at baseline, 10-week close of intervention, and 24-week follow-up.

Results

93 patients were determined to be eligible and completed the baseline interview. The majority of participants were non-White and Medicaid recipients. 78 (84%) completed the intervention and 10-week survey, and 58 (62%) completed the 24-week post intervention survey. Participants received an average number of 6.5 acupuncture sessions (out of a possible 10), and 4 yoga sessions (out of a possible 8) over the 10-week intervention. Patients showed statistically significant improvements in pain at the close of the intervention and at a somewhat lesser rate, at 24-weeks post intervention. Challenges included telephone outreach and site coordination integrating acupuncture with yoga therapy. The trial also had to be stopped early due to the COVID-19 pandemic.

Conclusions

Bundling acupuncture therapy and yoga therapy is feasible for an underrepresented population with chronic pain in urban community health centers with preliminary indications of acceptability and benefit to participants.

Manual and alternative therapies as non-pharmacological interventions for pain and stress control in newborns: a systematic review

BACKGROUND

Supporting therapies that provide stress and pain control of preterm and term newborns infants contribute positively to the neuropsychomotor development. Non-pharmacological interventions that involve manual techniques are described, considering protocols that can be reproduced by physical therapists, with positive and negative outcomes reports.

DATA SOURCES

Systematic review follows PRISMA 2020 statements guidelines. Primary and specific health sciences databases (Science Direct, Pubmed, Scielo, Embase and Scopus) were consulted between October 2021 and May 2022. Articles considered were clinical trials, randomized or not, that included descriptions of the type of intervention as non-pharmacological and that studied the following outcomes: "pain" and "stress".

RESULTS

Fifteen articles were selected for analysis, reaching a methodological quality of at least 3 on the Jadad Scale for the Quality of Researched Sources. The non-pharmacological therapies most applied in isolation were massage, swaddling or wrapping, gentle touch and kinesthetic stimulation, and the combined therapies were non-nutritive sucking and swaddling, oral sucrose and swaddling, sensory stimulation and familiar odors, and sensory saturation. The outcomes found were relaxation, pain, and stress reduction after the application of painful procedures. The behavioral changes included crying, grimacing, yawning, sneezing, jerky arm or leg movements, startles, and finger flaring. The vital signs included heart rate, blood oxygen saturation level, and pulse respiration.

CONCLUSIONS

Combined techniques lead to better results in controlling neonatal pain when compared to isolated techniques. They can be applied both in preterm and term infants in a safe way and are reproducible in any health unit in a simple and economical way.

Acupuncture and acupressure with improved cancer-related depression of retrospective studies

Introduction

Acupuncture and acupressure are widely used for treating cancer pain and depression and recognized as safe and effective by the international medical community. In this study, we systematically evaluated the efficacy, safety, and clinical significance of acupuncture and acupressure in treating cancer-related depression.

Methods

We searched MEDLINE, PubMed, Science Direct, Google Scholar, Web of Science and Embase and Chinese-language databases for randomized clinical trials (RCTs). To assess efficacy, rating scales administered by clinicians or experts were preferred, including the Hamilton Depression Rating Scale (HAMD), Self-rating Depression Scale (SDS), Self-rating Anxiety Scale (SAS), and Quality of Life Questionnaire-Core 30 (QLQ-C30) and the total effective rate after treatment. In all, Sixteen RCTs involving 1019 cancer patients were included in the Meta-analysis.

Results

Eleven (69%) of these studies reported the post-treatment total effective rate. Three hundred fifty-three patients received antidepressants; the total effective rate was 72.5%. Three hundred sixty-one patients underwent acupuncture and acupressure; the total effective rate was 90%. Meta-analysis results showed I² = 0%, no heterogeneity, (Z = 5.84, p < 0.00001); and combined OR = 3.55, (95% CI = 2.32 to 5.43).

Discussion

This study found that acupuncture and acupressure are as effective as medication in the treatment of cancer-related depression, provide a reliable basis for the clinical use of acupuncture to treat cancer-related depression, help promote nonpharmacological treatment for cancer-related complications. These approaches thus help reduce drug resistance and adverse reactions and improve patients' quality of life.

The effect of massage therapy on pain after surgery: A comprehensive meta-analysis

BACKGROUND

Findings on the usefulness of massage therapy (MT) in postoperative pain management are often inconsistent among studies.

OBJECTIVES

This study's aim is to conduct a meta-analysis of randomized controlled trials (RCT) to clarify the effects of massage therapy in the treatment of postoperative pain.

METHODS

Three databases (PubMed, Embase, and Cochrane Central Register of Controlled Trials) were searched for RCTs published from database inception through January 26, 2021. The primary outcome was pain relief. The quality of RCTs was appraised with the Cochrane Collaboration risk of bias tool. The random-effect model was used to calculate the effect sizes and standardized mean difference (SMD) with 95 % confidential intervals (CIs) as a summary effect. The heterogeneity test was conducted through I². Subgroup and sensitivity analyses were used to explore the source of heterogeneity. Possible publication bias was assessed using visual inspection of funnel plot asymmetry.

RESULTS

The analysis included 33 RCTs and showed that MT is effective in reducing postoperative pain (SMD, -1.32; 95 % CI, -2.01 to -0.63; p = 0.0002; I² = 98.67 %). A similar significant effect was found for both short (immediate assessment) and long terms (assessment performed 4-6 weeks after the MT). Remarkably, we found neither the duration per session nor the dose had an impact on the effect of MT and there seemed to be no difference in the effects of different MT types. In addition, MT seemed to be more effective for adults. Furthermore, MT had better analgesic effects on cesarean section and heart surgery than orthopedic surgery.

LIMITATIONS

Publication bias is possible due to the inclusion of studies in English only. Additionally, the included studies were extremely heterogeneous. Double-blind research on MT is difficult to implement, and none of the included studies is double-blind. There was some heterogeneity and publication bias in the included studies. In addition, there is no uniform evaluation standard for the operation level of massage practitioners, which may lead to research implementation bias.

CONCLUSIONS

MT is effective in reducing postoperative pain in both short and long terms.

Patients Receiving Integrative Medicine Effectiveness Registry (PRIMIER) of the BraveNet practice-based research network: Outcomes of the PRIMIER cohort

OBJECTIVE

To evaluate the real-world effectiveness of integrative medicine treatment on quality of life using the Patients Receiving Integrative Medicine Effectiveness Registry (PRIMIER).

DESIGN

A prospective, longitudinal, observational evaluation of patient reported outcomes for quality of life.

SETTING

Participants were patients from 17 integrative medicine clinics who received personalized, integrative medicine treatments between August 2013 and October 2017.

MAIN OUTCOME MEASURES

Participants completed the Patient Reported Outcomes Measurement Information System (PROMIS)- 29, Perceived Stress Scale-4 (PSS-4), and the Patient Activation Measure (PAM) at index (baseline) visit and at 2, 4, 6, and 12 month follow-up assessments. Electronic health record data included diagnostic and billing codes/descriptions. A linear mixed-effects model was used to test whether outcomes changed from index through 12 months RESULTS: During enrollment, 4883 participants began the assessment, 3658 completed the index measures, and 2374 (65 %) completed at least 1 follow-up assessment, had electronic health record data and at least 1 integrative medicine visit. Most participants (mean age=51.4 years) were white (88.4 %), female (79.7 %), and college-educated (78.5 %). Significant improvements (p < 0.001) were observed at 12-months on all PROMIS-29 measures, PSS-4, and PAM. At 12 months, clinically meaningful improvements were found for 38 % and 28 % on PROMIS-29 Mental and Physical Health Summary scores respectively.

CONCLUSIONS

PRIMIER is the largest study to assess the real-world effectiveness of integrative medicine. Results indicate a statistical and clinical improvement across all measures at 12 months. Future research could explore whether dosing, timing or combinations of integrative medicine interventions have differential impacts on quality of life.

Association of nonpharmacologic chronic pain management with function in a low-income population: Evidence from a survey of a sample of Latinos from five states

BACKGROUND

Low-income minority populations often confront barriers to professional nonpharmacologic management of chronic pain and, without this care, may have poorer daily function.

OBJECTIVE

To examine the association of professional nonpharmacologic chronic pain management in the past year categorized as physical interventions or mind-body interventions with current functional status.

DESIGN

Online, population-based survey.

SETTING

Community-dwelling Latinos from five southwestern states (California, Texas, Arizona, Nevada, and New Mexico).

PARTICIPANTS

The survey was offered to all Latino online panel members aged 35 to 75 years in 5 states (N = 1007). With weights, this sample represented 11,016,135 persons. Of 516 respondents (51%), 486 (94%) had valid surveys and, of these, 102 members (21%) had chronic noncancer pain. With weights, they represented 1,140,170 persons with chronic pain.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Daily impairment in mobility and in activities of daily living (ADLs).

RESULTS

Of the weighted sample, 37.2% reported daily impairment in mobility and 29.4% in ADLs. Professional physical interventions for chronic pain were received by 41.2% and mind-body interventions received by 33.4% but usually with physical interventions. Adjusted odds ratios (AOR) of daily mobility impairment for respondents who used physical interventions with mind-body interventions or alone were both less than 0.10 (p < .01) versus none. Only professional physical intervention was associated with decreased odds for daily impairment in ADLs (AOR = 0.07; 95% confidence interval = 0.01 to 0.94; p = .045).

CONCLUSIONS

In a weighted sample of Latinos with chronic pain, professional physical interventions reduced the likelihood of daily impairment in mobility and ADLs.

Non-pharmacological Treatment for Chronic Pain in US Veterans Treated Within the Veterans Health Administration: Implications for Expansion in US Healthcare Systems

BACKGROUND

Consensus guidelines recommend multimodal chronic pain treatment with increased use of non-pharmacological treatment modalities (NPM), including as first-line therapies. However, with many barriers to NPM uptake in US healthcare systems, NPM use may vary across medical care settings. Military veterans are disproportionately affected by chronic pain. Many veterans receive treatment through the Veterans Health Administration (VHA), an integrated healthcare system in which specific policies promote NPM use.

OBJECTIVE

To examine whether veterans with chronic pain who utilize VHA healthcare were more likely to use NPM than veterans who do not utilize VHA healthcare.

DESIGN

Cross-sectional nationally representative study.

PARTICIPANTS

US military veterans (N = 2,836).

MAIN MEASURES

In the 2019 National Health Interview Survey, veterans were assessed for VHA treatment, chronic pain (i.e., past 3-month daily or almost daily pain), symptoms of depression and anxiety, substance use, and NPM (i.e., physical therapy, chiropractic/spinal manipulation, massage, psychotherapy, educational class/workshop, peer support groups, or yoga/tai chi).

KEY RESULTS

Chronic pain (45.2% vs. 26.8%) and NPM use (49.8% vs. 39.4%) were more prevalent among VHA patients than non-VHA veterans. After adjusting for sociodemographic characteristics, psychiatric symptoms, physical health indicators, and use of cigarettes or prescription opioids, VHA patients were more likely than non-VHA veterans to use any NPM (adjusted odds ratio [aOR] = 1.52, 95% CI: 1.07-2.16) and multimodal NPM (aOR = 1.80, 95% CI: 1.12-2.87) than no NPM. Among veterans with chronic pain, VHA patients were more likely to use chiropractic care (aOR = 1.90, 95% CI = 1.12-3.22), educational class/workshop (aOR = 3.02, 95% CI = 1.35-6.73), or psychotherapy (aOR = 4.28, 95% CI = 1.69-10.87).

CONCLUSIONS

Among veterans with chronic pain, past-year VHA use was associated with greater likelihood of receiving NPM. These findings may suggest that the VHA is an important resource and possible facilitator of NPM. VHA policies may offer guidance for expanding use of NPM in other integrated US healthcare systems.

The Importance of Nutrition as a Lifestyle Factor in Chronic Pain Management: A Narrative Review

In everyday clinical practice, healthcare professionals often meet chronic pain patients with a poor nutritional status. A poor nutritional status such as malnutrition, unhealthy dietary behaviors, and a suboptimal dietary intake can play a significant role in the occurrence, development, and prognosis of chronic pain. The relationship between nutrition and chronic pain is complex and may involve many underlying mechanisms such as oxidative stress, inflammation, and glucose metabolism. As such, pain management requires a comprehensive and interdisciplinary approach that includes nutrition. Nutrition is the top modifiable lifestyle factor for chronic non-communicable diseases including chronic pain. Optimizing one’s dietary intake and behavior needs to be considered in pain management. Thus, this narrative review reports and summarizes the existing evidence regarding (1) the nutrition-related health of people experiencing pain (2) the underlying potential mechanisms that explain the interaction between nutrition and chronic pain, and (3) the role of nutrition screening, assessment and evaluation for people experiencing pain and the scope of nutrition practice in pain management. Future directions in the nutrition and chronic pain field are also discussed.

The clinician's guide to prevention and treatment of osteoporosis

Osteoporosis is the most common metabolic bone disease in the USA and the world. It is a subclinical condition until complicated by fracture(s). These fractures place an enormous medical and personal burden on individuals who suffer from them and take a significant economic toll. Any new fracture in an adult aged 50 years or older signifies imminent elevated risk for subsequent fractures, particularly in the year following the initial fracture. What a patient perceives as an unfortunate accident may be seen as a sentinel event indicative of bone fragility and increased future fracture risk even when the result of considerable trauma. Clinical or subclinical vertebral fractures, the most common type of osteoporotic fractures, are associated with a 5-fold increased risk for additional vertebral fractures and a 2- to 3-fold increased risk for fractures at other sites. Untreated osteoporosis can lead to a vicious cycle of recurrent fracture(s), often resulting in disability and premature death. In appropriate patients, treatment with effective antifracture medication prevents fractures and improves outcomes. Primary care providers and medical specialists are critical gatekeepers who can identify fractures and initiate proven osteoporosis interventions. Osteoporosis detection, diagnosis, and treatment should be routine practice in all adult healthcare settings. The Bone Health and Osteoporosis Foundation (BHOF) - formerly the National Osteoporosis Foundation - first published the Clinician's Guide in 1999 to provide accurate information on osteoporosis prevention and treatment. Since that time, significant improvements have been made in diagnostic technologies and treatments for osteoporosis. Despite these advances, a disturbing gap persists in patient care. At-risk patients are often not screened to establish fracture probability and not educated about fracture prevention. Most concerning, the majority of highest risk women and men who have a fracture(s) are not diagnosed and do not receive effective, FDA-approved therapies. Even those prescribed appropriate therapy are unlikely to take the medication as prescribed. The Clinician's Guide offers concise recommendations regarding prevention, risk assessment, diagnosis, and treatment of osteoporosis in postmenopausal women and men aged 50 years and older. It includes indications for bone densitometry as well as fracture risk thresholds for pharmacologic intervention. Current medications build bone and/or decrease bone breakdown and dramatically reduce incident fractures. All antifracture therapeutics treat but do not cure the disease. Skeletal deterioration resumes sooner or later when a medication is discontinued-sooner for nonbisphosphonates and later for bisphosphonates. Even if normal BMD is achieved, osteoporosis and elevated risk for fracture are still present. The diagnosis of osteoporosis persists even if subsequent DXA T-scores are above - 2.5. Ongoing monitoring and strategic interventions will be necessary if fractures are to be avoided. In addition to pharmacotherapy, adequate intake of calcium and vitamin D, avoidance of smoking and excessive alcohol intake, weight-bearing and resistance-training exercise, and fall prevention are included in the fracture prevention armamentarium. Where possible, recommendations in this guide are based on evidence from RCTs; however, relevant published data and guidance from expert clinical experience provides the basis for recommendations in those areas where RCT evidence is currently deficient or not applicable to the many osteoporosis patients not considered for RCT participation due to age and morbidity.

Palliative Care Early in the Care Continuum among Patients with Serious Respiratory Illness: An Official ATS/AAHPM/HPNA/SWHPN Policy Statement

Background: Patients with serious respiratory illness and their caregivers suffer considerable burdens, and palliative care is a fundamental right for anyone who needs it. However, the overwhelming majority of patients do not receive timely palliative care before the end of life, despite robust evidence for improved outcomes. Goals: This policy statement by the American Thoracic Society (ATS) and partnering societies advocates for improved integration of high-quality palliative care early in the care continuum for patients with serious respiratory illness and their caregivers and provides clinicians and policymakers with a framework to accomplish this. Methods: An international and interprofessional expert committee, including patients and caregivers, achieved consensus across a diverse working group representing pulmonary-critical care, palliative care, bioethics, health law and policy, geriatrics, nursing, physiotherapy, social work, pharmacy, patient advocacy, psychology, and sociology. Results: The committee developed fundamental values, principles, and policy recommendations for integrating palliative care in serious respiratory illness care across seven domains: 1) delivery models, 2) comprehensive symptom assessment and management, 3) advance care planning and goals of care discussions, 4) caregiver support, 5) health disparities, 6) mass casualty events and emergency preparedness, and 7) research priorities. The recommendations encourage timely integration of palliative care, promote innovative primary and secondary or specialist palliative care delivery models, and advocate for research and policy initiatives to improve the availability and quality of palliative care for patients and their caregivers. Conclusions: This multisociety policy statement establishes a framework for early palliative care in serious respiratory illness and provides guidance for pulmonary-critical care clinicians and policymakers for its proactive integration.

Acupuncture versus massage for pain in patients living with advanced cancer: a protocol for the IMPACT randomised clinical trial

INTRODUCTION

Pain, comorbid fatigue and sleep disturbances are common and distressing symptoms for patients with advanced cancer, negatively impacting their quality of life. Clinical guidelines recommend non-pharmacological interventions, including acupuncture and massage, for pain management in adult patients with cancer in adjunct to conventional care. However, high-quality evidence about the comparative effectiveness and long-term durability of these therapies for symptom management is limited.

METHODS AND ANALYSIS

We describe the design of a two-arm, parallel group, multicentre randomised controlled trial that investigates the use of acupuncture versus massage for musculoskeletal pain among 300 patients with diverse types of advanced cancer. The primary aim is to evaluate the long-term effectiveness (26 weeks from randomisation) of acupuncture vs massage for pain (primary outcome) and comorbid symptoms (fatigue, sleep disturbance and quality of life). The secondary aim is to identify patient-level demographic characteristics (eg, sex, race, age), clinical factors (eg, insomnia, pain severity) and psychological attributes that are associated with a greater reduction in pain for either acupuncture or massage. Patients will receive weekly acupuncture or massage treatments for 10 weeks, followed by monthly booster sessions up to 26 weeks. The primary endpoint will be the change in worst pain intensity score from baseline to 26 weeks. We will collect validated patient-reported outcomes at multiple time points over 26 weeks.

ETHICS AND DISSEMINATION

The Institutional Review Board at Memorial Sloan Kettering Cancer Center in New York approved this protocol. Results will be disseminated via peer-reviewed scientific journals and conference presentations. Our findings will help patients and healthcare providers make informed decisions about incorporating non-pharmacological treatments to manage pain for patients with advanced cancer.

TRIAL REGISTRATION NUMBER

NCT04095234.

Educational courses on non-pharmacologic complementary interventions for nurses across Europe: The INES mapping pilot study

BACKGROUND

Pharmacological interventions still form the mainstay of the management of pain, anxiety, sleep problems and discomfort. In Europe, an estimated 100 million people use complementary non-pharmacological interventions (NPIs) for these conditions. In their pre-registration education, nurses do not generally learn about the various types of NPIs and how patients and health care professionals can include NPIs complementary to their standard care. Some nursing schools in Europe offer elective courses on NPIs, often relying on individual initiatives. Little is publicly available about the content of these programmes and how they relate to the current nursing curriculum for EU countries.

OBJECTIVES

This pilot study aims to explore and map the field of nursing education with regard to complementary NPIs for nurses in Europe.

DESIGN

A web-based open-access questionnaire administered through the online survey tool LimeSurvey® was designed by the authors.

PARTICIPANTS

The questionnaire was sent to a purposive sample of 49 experts on nurse education and complementary NPIs from 16 European countries. All levels of education were eligible for inclusion.

METHODS

The questionnaire consisted of 35 items regarding course content, teaching material, teaching methods and methods of assessment. In addition, respondents were invited to perform a strengths, weaknesses, opportunities and threats (SWOT) analysis in relation to their education programme. Qualitative data was analyzed using a directive content analysis approach.

RESULTS

Between January and May 2020, thirty-one completed questionnaires from ten different countries were returned (response rate 63.3%). Massage, meditation, mindfulness and relaxation are the most taught interventions. Anxiety, stress, chronic pain, depression and sleep problems are the most common symptoms addressed.

CONCLUSIONS

Currently, a consistent and European approach to education for nurses on complementary NPIs and integrative nursing is lacking. Although taught at regular nursing educational institutes, the courses discussed here are not yet embedded in mainstream education for nurses.